Healthcare Provider Details

I. General information

NPI: 1124089370
Provider Name (Legal Business Name): MANISH KUMAR MADAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 RIDGEWAY AVE SUITE #100
ROCHESTER NY
14626-0000
US

IV. Provider business mailing address

2440 RIDGEWAY AVE SUITE #100
ROCHESTER NY
14626-0000
US

V. Phone/Fax

Practice location:
  • Phone: 585-720-1550
  • Fax: 585-720-1553
Mailing address:
  • Phone: 585-720-1550
  • Fax: 585-720-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number172120
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: